1. Success Stories that Inform Effective Counseling Approaches with People in Homelessness Rebecca R.S. Bertram, Psy.D. University of Saint Thomas Mental Health Systems, PC

2. Introduction to the Study Doctoral project University of Saint Thomas Results will be interweaved with current research literature to inform practice implications

3. Learning Objectives Recognize experiential aspects of homelessness Identify possible strengths or resilience factors for people experiencing homelessness Apply research and practice implications for clients in homelessness

4. https://www.youtube.com/wat ch?v=THxtcWNw3QA [Taken from Rethink Homelessness organization through Orlando, Florida]

5. Introduction Homelessness as a significant community issue Nationally: 610, 042 people were homeless in January 2013 (The National Alliance to End Homelessness, 2014) In Minnesota: At least 10,214 people were homeless in 2012 on any given night (Amherst Wilder Foundation, 2013) Image taken from http://queenslibrary.force.com/HOC__cmscontent?CMSId=a0Uo0000 0002TyLEAU

6. Introduction Significance to psychology Experience of homelessness has clear psychological impacts (American Psychological Association, 2010; Bentley, 1997; Davis, 1996; Eynan, Langley, Tolomiczenko, Rhodes, Links, Wasylenki, & Goering, 2002; Kuhlman, 1994; Liu, 2008; Lott & Bullock, 2007; Markos & Lima, 2003) Many factors can contribute to homelessness, however: Correlation between mental health issues and homelessness In Minnesota, 60% of homeless individuals reported serious mental illness in 2012 (Amherst Wilder Foundation, 2013)

7. Literature Review What is included Adults Intervention-focused What is not included Homeless youth Assessment literature

8. Literature Review Risk factors to homelessness Combining data from the Bureau of Justice Statistics & the National Alliance for Homelessness (2012) Odds of experiencing homelessness after being discharged from prison= 1 in 13. Combining data from the Department of Health and Human Services & National Alliance for Homelessness (2012) Odds of a youth person experiencing homelessness after aging out of the foster care system= 1 in 11. Who is homeless today Acknowledging heterogeneity and common demographics

9. Literature Review Systemic factors that intersect with homelessness Lack of affordable housing, inequities related to the education system, foster care system, social alienation of homeless people, insurance system, disparities in the judicial system, changes in the job market Role of psychologists Larger economic shifts Mass incarceration of people of color, as it relates to housing (Alexander, 2010) Disproportionate sentencing of people of color as compared to Caucasians Felony charges and housing

10. Literature Review Culture of poverty Cultural values (Payne, 1996) Level of discrimination and experiences of oppression (Sue and Sue, 2013) Working with people in poverty Guidelines for interventions (Foss, Generali, and Kress, 2011; Sue and Sue, 2013)

11. Literature Review Preliminary guidelines for working with clients in homelessness Action-oriented and collaborative processes (APA Presidential Task Force, 2005; Foss, Generali, & Kress, 2011; Sue & Sue, 2013) Flexibility in the counseling role (American Psychological Association, 2010; Sue & Sue, 2013; Toporek et. al., 2006; Koegal (as cited in Bentley, 1997) Relationships, support, and safety (American Psychological Association, 2010, Bentley, 1997; Combs, 2012; Speirs, Johnson, & Jirojwong, 2013; Tischler, Rademeyer, & Vostanis, 2007) Collaboration with other resources (American Psychological Association, 2010, Miller, 2011; Sue & Sue, 2013)

12. Issues in the Literature Not enough data specific to counseling people in homelessness Focus on pathology over strengths Risk of reflecting societal stereotypes in the research Homelessness occurs disproportionately to people of color Need for strengths-based, multi-culturally aware, and client-focused data to appropriately implement multi-culturally competent research. Risk of bias in the literature itself, and in misinforming psychologists about effective interventions with multicultural populations. Where is the client’s voice? Focus on the author’s perspective Likely different SES background and perspective

13. Statement of the Problem Local psychologists have limited research on working with this population Risk of utilizing ineffective interventions, and/or re-enacting experiences of oppression with clients Need more data

14. Research Question What can clients tell us about the experience of homelessness, the transition out of homelessness, and counseling during homelessness that can help guide future counseling interventions?

15. Investigative Methods for the Current Study Success stories Qualitative methods: Interpretive Phenomenological Analysis (IPA) Goodness of fit for purpose of the study Sampling and data collection Criteria to be eligible Semi-structured interviews

16. Participant demographics

17. Interview QuestionFollow Up Questions What do you wish counselors understood about what it’s like to be homeless? What are other people missing about what it’s like to be homeless? Tell me about your success story. What were the most important parts of your success? What was most helpful to you during this transition out of homelessness? What was counseling like for you? What were you impressions of counseling and of your counselor? What role did counseling play in your success story? What worked in counseling and what was difficult in counseling? What was most helpful that your counselor did? What was least helpful?

18. Immersing oneself in the script: Reading and re-reading In text: Intonation of speech Right margin: Exploratory comments Left margin: Emergent themes Coding script Cutting the script into chunks Connecting and abstracting themes within each script Sorting into within script themes Color-coded notecards Analysis Process

19. Connecting and abstracting themes within each script (Continued) Connecting and abstracting themes across scripts Grouping into super- ordinate themes and sub-themes Finalizing super- ordinate themes and sub-themes Results of the study Analysis Process

20. Types and levels of within- interview methodological measures to increase trustworthiness Interview Number Within-interview methods utilized to increase trustworthiness Level of within-interview analysis for these methods 1Auditing Coding, emergent themes, themes within transcript 2Validity check with participant Themes within transcript 3Auditing Coding, emergent themes, themes within transcript 4Validity check with participant Themes within transcript 5Validity check with participant Themes within transcript 6Validity check with participant Themes within transcript 7Auditing Emergent themes, themes within transcript 8 Auditing and Validity check with participant Emergent themes, themes within transcript 9Validity check with participantThemes within transcript

21. Additional Measures of Trustworthiness Auditing also occurred across scripts, at the level of super-ordinate themes and sub-themes Reflection journal for the researcher

22. Ethical and Diversity Issues Approved by IRB within UST Stirring up old emotions and experiences Informed consent and resources provided Structural and systemic barriers Avoiding the assumption that counseling played significant role Lack of researcher personal experience with homelessness & risk of replicating biases Reflection journal, validity checks, auditing Qualitative methods to capture the participant’s voice rather than the researcher’s voice

23. Results: What the Participants Said 9 super-ordinate themes 27 sub-themes

24. Understanding the complexity and diverse face of the homeless condition. Wide variety of factors leading to homelessness. Recognition that anyone could experience homelessness as a part of the human condition. Homelessness as a lifestyle for some people in long-term homelessness. “I would wish that they understood that we are not cut from the same cloth...Not everybody is homeless for the same reason.” “You can’t just judge us all on the same thing. We only got one thing in common, we’re homeless, and that’s the only thing we got in common. That’s it and nothing else.” “You ain’t be but one step from being homeless too.” “You can be highly educated, you can be highly intelligent and you could be highly successful and still end up homeless due to a variety of weird reasons coming together at the same time.” “They’ve been camping outside for the last 20 years. You can’t put them in a house because, like they once said, ‘I can’t live inside. I’ve been out here so long this is the only way I can live now.’”

25. Terrell: previous business owner, financial losses Shelton: college educated, only child of single mother, death of mother, substance use, financial loss Sue: substance use, Keaton: college educated, caring for a dying family member in another state, financial losses, loss of job “But you just had to ride home from work, boss was tripping just cut your hours, told you the checks might be three days late, then you get in a car you hear the right tires making the noise, the headlight was blown out on the right hand side and you look at the gas tank and it’s right…it’s almost behind the red light.” “I was always smart academically and always worked the course…I don’t know what the hell happened. I just lost it. And I think that was because I was so lonesome-I think so.” “I was replacing the drugs and the alcohol to keep my mind from not thinking about that stuff.” “Okay, when my father passed I had all kind of expenses, my dad he didn’t manage his resources very well. So all the resources that he had, I had to take care of his burial, take care of any debts that he had after with the resources. So when I got through it I had no money, so that’s what led to me being homeless.”

26. Larry: laid off after 9/11 Carson: married over 20 years, owned a house, substance use, loss of marriage led to leaving his home Felony history barrier Bob: loss of relationship led to homelessness, and then further substance use Felony history barrier Victoria: unsure whether it was voices or her spirituality Charlton: substance use Felony history barrier “it was the after effect of 9/11 because everything with the jobs and everything was going downhill and had to recover from the loss, like the loss of the Twin Towers. Somehow all of that had to get replaced, it was like a ripple effect, everybody felt that you know. But especially the poor because they don’t have job security.” “started drinking too much, but then I quit for a while, but then after 20 years my old lady got tired of it. You know so, that’s how I ended up back in the streets.” “I just went on a real, down-spiral binger you know, all day, every day.” “a voice came which, it could have been the voices or it could have been a spirit, I’m not sure which, but it told me I have to leave Maryland.” “well to be honest with you, I lived on drugs for years, and right now I’ve been clean 10 years. I was in and out of the penitentiary supporting my drug habit, and right now, I haven’t been in trouble in like 13 years, 14 years.”

27. Devastating aspects of the experience of homelessness. Negative psychological effects of experiencing homelessness. Vulnerability to theft, violence, and damage to physical health. Experiences of isolation, stigma, and discrimination. “…depression, pain, sadness, unhappiness, and kind of just going off your survival instincts.” “I had blisters all over my feet, blood blisters on top of my toes, top of my toenails where I got blood, because I couldn’t afford to buy shoes that fit me, I was just so poor.” “If a person is homeless when they go out into the general population and the general population sees a homeless person, they stigmatize that person and they stigmatize them by the way they are reacting. If you have ever been homeless and you are on a bus or train and that person sees you with a bunch of bags, they move away from you. They feel like you are going to hurt them because they think, I mean they make you feel inferior to them because you are going through this difficult situation. And they do it by their actions and they do it by how they look at you.”

28. Homelessness in context: understanding systemic factors involved. Barriers to qualifying for housing. Gaps in necessary resources to transition out of homelessness. Use and misuse of resources pertaining to homelessness. Experiences of homelessness specific to the state of Minnesota. “Everyone is not there by choice, you know. It is really hard, like I say for some people. It is really hard, such as myself. I use myself as an example, it was very hard for a long time because I have a criminal background and they got my credit, which it was good I don’t have bad credit. But that criminal background, other than that, that’s the thing that was just knocking me down. I can’t go to any regular apartment building and get an apartment because it is the only thing they see that I have a felony on my record. That takes me out right off the bat. They don’t need to go no further.”

29. https://www.youtube.com/watch?v=DcD1d9Ek2s4 [Taken from Rethink Homelessness organization through Orlando, Florida]

30. Resilience and strength factors in people who transition out of homelessness. Reframing experiences with a perspective that is preparation-focused, positive, strengths-based, or focused on gratitude. Persistence through difficult situations, repeated rejections, and isolation. The helpful role of spirituality, prayer (to God or ancestors), and connection to a church in transitioning out of homelessness. “It's like you can complain about not having a house but it’s like at least I'm living, everyday God has given me….I can still walk, I can still talk, I'm still alive, I'm still talking here.” “I’m searching, I’m fishing. I might have to search late and keep the fish on the water, I might have to fish all the worms, I might have to fish with a hook with no bait on it and might get a bite.” God might “let somebody be watching what you just went through, because when they go through it they’ll be able to say, ‘well I seen sister so and so,’ or ‘I remember he lost his job and everything all in the same week, but look at him now. He didn’t give up, he didn’t kill himself, he didn’t go through, he didn’t kill nobody, he didn’t rob no bank.’”

31. Importance of creating an effective support system to transition out of homelessness. Creating a positive support system with a wide variety of professional and personal supports. Importance of avoiding contact with past substance-using acquaintances. “So if you got somebody motivating you, like they say don’t work out by yourself. Work out with somebody that’ll be going that extra mile. So that’s what I basically did. I just kept surrounding myself with a network of people, just building on that until it came together. That’s what it did, it came together.” “I don’t hang with that negative crap no more because if I was hanging with you, I’m going to end up what I’ve been doing for these three years over here. I’m going to lose it because what you want to do is trying to get high on something. It ain’t happening today, I’m not doing that today.”

32. Factors involved in taking an active, personal role in transitioning out of homelessness. Importance of being personally accountable to transition out of homelessness in response to the necessary supportive programming and resources. Role of identifying personally meaningful goals and motivation to transition away from substance use and/or homelessness. Role of maintaining sobriety to obtain stability and transition out of homelessness. Importance of stabilizing mental health by taking psychiatric medications. Importance of proactively networking (personally and professionally) to seek out employment and housing opportunities. “I mean how can I put it? It had to be me. I had to look for the job, find the job, send out the resume, make the phone call, fax the resumes. I had to do the work but they were supportive of me.” “Number one is to stay clean and off of drugs and number two, staying out of trouble, and number three, getting a job.” “I got a dream. Like I just wanted to be going by, being straight, going to church, having a job, and my baby beside me. I just think of that and that’s what makes me keep straight.”

33. Mixed experiences with counselors while homeless. Helpful counselors show they care and are invested in their relationship with you. Other qualities of helpful counselors. Varied barriers and drawbacks in counseling. “Her number one priority was me. And you know, when you work with good people, you want to also do good for them.” “I think it’s all about knowing that there is someone that cares about you and they are out to help you. It’s about having a relationship with somebody who’s really trying to work with you to help you get out of that situation. I think the relationship is number one. “They don’t really do anything. They have all these people handing these cards, and they don’t provide any counseling or anything. You’re just there, you are just a number with these folks…they probably don’t have the skill level to do it.”

34. Benefits of group and individual counseling to people experiencing homelessness. Counseling provides a positive emotional outlet. Group counseling helps you know you are not alone, provides hope, and helps you find resources. Capacity metaphor “Like a person strung out on drugs. You can be strung out for 10 years, 20 years, and I've been strung out for 2 years. And I'm thinking there's no way to get away. But you’ve been strung out for 10 or 20 years and you got away and you been led a successful productive, name in society. Everything is ok, that’s the hope at the end of the tunnel. That’s the light I can see, I can see it in you.”

35. The essential role of housing, employment, financial, and other basic needs resources in transitioning out of homelessness. Helpfulness of counselor or mental health practitioners coordinating resources, providing referrals, and providing practical help to transition out of homelessness. Supportive or transitional housing as an important next step toward obtaining permanent housing. Types of resources People in homelessness “just need somebody that can guide them in the right direction, tell them what kind of resources they could use that might help and get them out of there and get them someplace to stay.”

36. Implications Research and Practice Strengths and limitations of findings Qualitative data: rich stories and information, yet results need replication Participants Generalizability Please note: **two-starred implications align with current literature, *one- starred implications have some limited support in the literature, and un- starred implications have very limited support in the literature to date

37. Practice Implications *Balance knowledge of risk factors to homelessness with the understanding that homelessness occurs across many different types of people and contexts. **Engage in continual self-reflection about personal assumptions. *Incorporate awareness of physical, psychological, and social wellbeing effects of being homeless *Felony history may all for special attention *Ask practical questions to assess whether or how systemic barriers occur

38. Practice Implications *Utilize counseling skill sets to reframe perspectives to build on resilience, strengths, and gratitude. *Consider assessing clients’ spiritual or religious orientations at intake. **Assess support systems of clients and work to maximize positive sources of support. Balance providing resources with individual accountability. *Showing clients how to use the resources, without doing the work for them. *Incorporate motivational interviewing and collaborative processes of counseling.

39. Practice Implications **Apply common factors research about caring relationships in counseling (may be particularly important, given isolation). *Embrace some flexibility in your role as psychologist in ethically appropriate ways. *Assess client’s cognitive needs, and adjust vocabulary and interventions as needed *Utilize counseling skill sets to explore skills and strategies for clients to find emotional outlets Including additional non-counseling resources for emotional outlets

40. Practice Implications Consider opportunities for group counseling with clients in homelessness. *Learn about local resources, and actively refer clients to and coordinate resources. Handbook of the Streets by St Stephen’s human resources *Be ready to work as part of a team of workers for clients *Utilize hands-on, practical approaches to assist clients with practical issues. *Understand the important role of supportive or transitional housing

41. Research Implications Role of repeated rejection with people in long-term homelessness. How people in long-term homelessness affect other people in homelessness Help-seeking behaviors for medical and psychiatric care Additional resilience studies Strategies for clients to use to build the effectiveness of these support systems, especially in a culturally appropriate manner that respects the person’s inter-cultural communication style Research needs to be intentional about balancing individualistic and systemic factors involved in homelessness

42. Research Implications Motivational interviewing in homelessness Effectiveness of flexible role of counselor, and how to balance this with ethical considerations How clients’ demographic factors (such as education, criminal history, or ethnicity) influence the perceived responses of staff interventions Varied experiences with participants perceptions of staff help Effectiveness of group counseling for people in homelessness. How to balance resource coordination with client accountability across different types of clients and different experiences of homelessness.

43. Other Findings that Call for Additional Research The effect of age and “maturity” on transitioning out of homelessness One participant explained that he “just grew up” Future research on natural developmental processes aide in moving out of homelessness, depending on the type of homelessness experienced Practicing staying at the shelter “once you know you will be homeless” soon Only one participant utilized this strategy He used the stay to find out where to go, and asked other people at the shelter about what he would need to do on a day to day basis such as where to eat, and resources he should know about Helped him feel better and know what to do when he became homeless

44. Follow-up on Learning Objectives Recognize experiential aspects of homelessness Identify possible strengths or resilience factors for people experiencing homelessness Apply research and practice implications for clients in homelessness **If you would like a table summary of results and implications… Refer to additional handout

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50. Thank you to… The participants who shared their stories People and agencies sharing information about the study, especially Tim Balke, Margaret Miles, Cathy ten Broeke, and Catholic Charities Doctoral project committee: Dr. Renninger, Dr. Frank, and consultant Dr. Stankovitch Auditor: Dr. Naomi Scott